The Recall Journey is complete. We now have a governor who shares much of our vision for California. We must now work to bring about transformation of our state into a kind and just place, a land of opportunity for the rich and poor alike. Please join us in the hard work ahead.
Governor Schwarzenegger has declared 2007 the Year of Universal Healthcare. Dr. Matsumura has been writing here about the plight of the working poor, which triggered the launch of the recall campaign. In a series of articles below, Dr. Matsumura describes the problem as he sees it and makes a proposal that could cut our healthcare budget by 55%.
January 17, 2008
You know, 9 days ago when I posted here, it was after a long absence and I really wondered if I was just wasting my time posting here anymore. Our study shows that we still have quite a few readers who rushed here upon my posting. I have to confess, I am pretty arrogant and a "know it all" but I feel humbled that people still read what I write here as if it mattered. And in case you folks in the Governor's camp are wondering, my lieutenants are NOT talking about starting up another recall campaign! I came here today mainly to fix a typo I saw in my last posting (I no longer have the benefit of a whole bunch of my people proofreading for me), but so that you are not reading just trash, I would like to share with you what I see that no one else seems to see. Am I really the only one?
I am referring to the debacle of the mortgage industry and the three million foreclosures newspapers keep tallking about. Almost everyone - no, everyone, except me, blames the subprime mortgage lenders for the trouble, and legislators all think that by outlawing some of the mortgage lending practices, they can fix the problem. Boy, are they all off the mark!
The culprit is the repeat and unnecessary raising of the interest rate by the feds - the interest rate that governs all the mortgage interest rates. You recall, the recession after the 9-11 calamity forced the feds to lower the rate to a historic low. Interest rates are lowered to encourage borrowing and stimulate businesses to invest in expansion. When after a few years, the feds began to raise rates, almost at every chance they got, by a quarter of percentage each time, I looked to see if their raising rates was justified by economic indicators. Usually, one raises rates if there is a danger of inflation. I am quite versed in these matters because my business lives or dies on my pegging the direction that the economy is headed and my people and I agreed that there was little indication of inflation looming. THERE WAS NO REAL NEED TO RAISE THE RATES. I was puzzled. I did say publicly that these unnecessary raising of interest rates will have a major impact on all those new homeowners (and old ones who refinanced) who took the option of getting mortgages with variable interest rates - you know those mortages whose payments are low when the interest rates are low, but those whose payments go up as the fed's interest rates go up. When the rates finally ended up something like 3 per cent above the start, I warned that there will be a huge foreclosure debacle. Guess what happened?
The so called (denigrated) sub-prime lenders weren't lending only to people with poor credit histories. They really came up with many creative designs of mortgages that enabled ordinary people to taste the American Dream of home ownership. Some of the mortgages were intended to raise the monthly payments after awhile, typically five years, but allowed payments to be lower in the first few years. Such creative mortgages allowed younger borrowers who had just entered the job market to buy homes. What a wonderful service they provided. These younger borrowers were able to buy homes before home prices got so high they would be shut out of the market forever. The rationale for these creative mortgages were not irresponsible. Not at all. If there is anything I know about more than medical technology, it is real estate. I saw that these creative loans did mostly good. Borrowers, after five years in workplace, are getting more pay after a few years and if the bump up in the payment couldn't be met, it was reasonable that they could get refinanced to a plan that they can afford. That was a common practice in real estate. Young borrowers with almost no credit history can build up their credit scores so that they can get into new loans paying less interest rates. Then too, with the historical trend assuring real estate prices steadily rising, one can refinance after a few years when the home prices have gone up building owner's equity in the property so that when one refinanced, homeowners would be borrowing less money in proportion to the value of the property (loan to value ratio lower) such that the lenders would offer loans at a lower rate than before. So all kinds of safeguards were there for homeowners. What they didn't plan for was the sinister meddling of the interest rate by certain monied interests in this country. The fed interest rates went up. There was little evidence looking at economic indicators for need to raise them. Certainly not 3% raising! They were raised by certain people. There wouldn't be all these foreclosures if they hadn't raised them. So why are we scapegoating the creative lenders who did so much good?
Traditional banks lost a lot of money to "subprime" lenders, because they did not have the kinds of creative loans that matched consumers' needs. The raising of interest rates have bankrupted most of these creative lenders so that soon, all consumers will have to go to the traditional banks and take what they offered. Banks are lobbying legislators to bar creative mortgages. And then I heard the news that topped everything. Most subprime lenders have had to lay off thousands of workers (why is California facing deficits?), and many have bankrupted, but a few large ones survive, barely. Their stocks, like Countrywide Mortgage, have plummeted to 25% of their original price. These companies are a prime target for sharks. Bank of America announced they have bought Countrywide, at a bargain basement price. They bought assets of Countrywide at a rate of 25 cents on a dollar! What shrewed business people! The people have lost a bundle!
Why is California suffering deficits? One reason is that home prices have collapsed. Why did they collapse? When so many homes are on foreclosure sale and you can buy them for 60 cents on a dollar, home prices in general decline. When prices decline, homeowners tend to hold on and delay selling, if they can, and so the number of home sales drop. With a decline in home sale, revenue to counties and the states declines sharply since these governmental entities receive money when homes sell.
What do you all need to do? Do I need to tell you?
January 8, 2008
Assessment of the State of the State speech by Gov. Schwarzenegger. Three years make a lot of difference. His plea for healthcare for all was beautiful to listen to. The future of his health plan is in doubt especially because the economy has gone south. I have a feeling that no one's health plan will get the support of the people unless it results in a reduction, not increase, in healthcare cost.
For awhile, I thought that a healthplan that will cover the working poor will be passed, and can be the bridge until a complete overhaul of America's health care is made. Now I think that nothing will change without a comprehensive overhaul first.
The single payer healthcare doesn't work, as one can see with the Canadian example (see below), and people may not be willing to spend any money to cover the working poor. I recommend that my American Medi-Plan (SM) be used as the basis for a complete overhaul. The current legislature and Governor Schwarzenegger have 23 months before their terms are up. If we all work together, the new California Medi-Plan (SM) can be the most important legacy they will leave behind when they bid farewell to Sacramento. Write me at firstname.lastname@example.org so that we can work together.
November 7, 2007
I am pleased that both sides are working to produce a compromise that will benefit the working poor who have been cheated out of anything good about America's health care.
The bill that will emerge and be signed into law will necessarily be a stopgap measure because fundamentally, we are just patch-working into a sick system. If fundamental changes are not made, our health care system will bankrupt or more to the point, it will bankrupt us. One proposal is to adopt a model of a single payer system. The Canadian system, which is the model often touted by the proponents of the single payer system, is about to bankrupt. Canadian patients can't see specialists for months, and can't get MRIs for 9 months. The British model is worse. I am dealing daily with UK citizens who are fleeing their health care system in which patients don't get to see their oncologists for two years after the diagnosis of cancer! Their system is so bad now that it appears they don't even know how the rest of the world treats their sick.
The fundamental change I proposed is to 1) return the responsibility of paying the providers of health care (doctors, hospitals, laboratories, etc.) to the patient - insurance companies and the government will reimburse the patients, and 2) restore competition to the health care sector. Doctors and hospitals are allowed to charge whatever they want to and they will see their patients flee to those who operate efficiently and charge less, but without short-changing the patients. These fundamental changes will severely reduce our health care expenditures, increase hospital bed capacity to meet civil disasters, and make our health care providers more responsive to patients, even returning housecalls like in the fifties.
Alin Foundation and I will be making a formal presentation to the country in about the second year of the next Presidency, and we feel pretty confident that our proposal will be accepted by the nation.
July 21, 2007 There has been a dramatic development in Dr. Matsumura's cancer research work, which has demanded that all his time and resources, as well as those of Alin Foundation, be committed towards it. He has asked us to tell you that he hopes to resume his postings here on August 10th, but regardless, you will all be glad that he is focused on this wonderful development.
June 9, 2007 So we are getting ready to detail out more of the American Medi-Plan (SM). With the risk of repetition, because so many people reading here are new, I am going to begin summarizing features for the last time. Those who already know what I write today, please bear with me.
Why should we return to paying our doctors and
May 5, 2007 I (Kenneth Matsumura) have not been able to write here much or complete the polishing up of my American Medi-Plan (SM) due to my needing to put a lot of attention on Alin Foundation cancer project (described in my note below of February 14, 2007). We received a desperate plea from a devoted father of a 7 year-old boy in South America with leukemia, who is just weeks from dying. The brave little boy has been treated with the world's best chemotherapeutic agents and at where we can determine to be a first class institution. Nothing has worked. Our work with the medicaments called FAN-C that eliminate side effects of cancer chemotherapy and which make ordinary cancer drugs suddenly turn into super-drugs to eradicate all kinds of cancer was designed mainly for solid tumors, not blood cancers (great with lung and breast cancers). However, when we were asked to treat another desperate leukemia case a few years ago, we succeeded to put the patient into an incredibly long remission and so we have reason to be encouraged that we can help this boy. It is not good that we got him so late in his disease, but we will try anyway.
I had a few minutes to share a few thoughts. First, I was keenly disappointed that budget consideration is putting the San Francisco-Los Angeles Bullet train on a delay. THAT is a bad decision, from all kinds of consideration. California's population growth warrants such a train and assures economic viability. Our roads are congested and to combat global warming, we must reduce automobile congestion. Such a train can spur economic growth of areas like North Los Angeles, and that will result in additional tax revenues. If we don't want to raise taxes in the future, we must speed up our economic engine. Don't backburner the super-train! France just broke the world record with their train going over 350 miles per hour. How I would love to be able to go back and forth between NoCal and SoCal in a couple of hours! Where I give preference in my business to NoCal firms because of the distance to SoCal, such a train would make me recommend strongly to all my subsidiaries and affiliates to not bias the geography. If I think I would do that, I can imagine a lot of other CEOs would probably do that. It can also unite this state. Please reconsider the decision to not adequately fund the California bullet trains.
I had an opportunity the other day at the Coro (Foundation) Northern California luncheon to hear Andy Stern speak passionately about moving our country once again, and especially about health care. He made a very good case for not taxing or making corporations bear most of the burden of health care for their employees and others. Such a burden is making AMerican corporations lose the competitive edge against foreign companies. For example, now, too much cost of American cars pays for workers' health coverage; true, that isn't the only reason General Motors is losing to Toyota who also manufactures in the United States, but I have always felt that we taxpayers and voters go to the business too often to fund our social needs. You know how socially progressive I am, but I simply vote "no" when I see that people are not willing to share the burden but expect businesses to pay for more and more.
Governor's health proposal tried to be fair in that he wanted everyone to share in paying for the health coverage for our working poor. I like that better, but as you have seen if you have been reading here since February, there is no solution to the American health crisis until we figure out ways to rope in the runaway costs.
To summarize what I propose in my American Medi-Plan (SM) are:
Every American is given a life-time allowance for health care costs - however, rather than one lump sum that would be kept track of, the total amount, for example, 1.6 million dollars is broken up into smaller segments, such as $75,000. Computerized tracking follows everyone's spending for health care, and identifies those individuals who may need closer scrutiny. No this is not Big Brother; third party payers already do this, but do it poorly making decisions instead on the average behavior of people. So the government and insurers resorted to the Diagnosis Related Groups DRGs. This is the most "expedient" measure when a word such as "expediency" doesn't belong in health care. At least when they started to use this provision (it's better now), when one entered with a diagnosis of pneumonia, the insurers averaged the stay period of everyone and decided that the average was 2.3 days, and so that was how long they were going to pay for care. I tended to have older patients, who healed more slowly, and 2.3 days were not enough. I was not going to tell the relatives of an 89 year-old grandmother who was so weak from pneumonia that she can barely lift a spoon, that 2.3 days were up and she had to go home. This was trying to make everyone act like an average. What I propose is that we stop wasting time and money inspecting each and every spending, since catching the abuse is costing more money than the abuse is costing the system. Instead, we rely on each and every individual to watch their bills and their spending because each and everyone knows that they are (he or she is) alloted a finite amount of health care dollars, afterwhich they will lose considerable freedom in getting cared for. By making every patient study the bills before paying them, one will do a far superior job of catching abuse and errors than any Blue Cross clerk reviewing hundreds of bills each month. Doctors and health care providers will suddenly become far more careful in how they bill lest they be embarrassed or raise the ire of a dear patient.
The American Medi-Plan (SM) will be watching everyone's spending and observing how much anyone may be deviating from the average. Those who are, will get more review and scrutiny, but the difference from today's system is that we will be able to do away with about 95% of the reviewers, and doctors will once again start taking care of patients, not spend a quarter of their time with paper work or dictating reports to clerks who have no idea what kind of care a patient really had from the doctor.
There will certainly be those who are over-anxious about running out of their health care dollars, and postpone seeking medical attention until it becomes even more expensive to treat their conditions. I pointed out below that we will work into the Medi-Plan provisions that will encourage early diagnosis and preventative care. In fact, there will be penalty provisions to those who didn't bother and let their condition get so bad it became three times more expensive to care for them.
Much of the penalty I talk about is in the loss of freedom. You know how much Americans love freedom.
Most Americans have insurance through their jobs or by buying them privately. What American Medi-Plan envisions is that we would continue to pay something for our coverage. However, those who earn less will pay less and those who can afford more will pay more. The savings that will result from the innovative design of the American Medi-Plan will pay for the premium of those who can't afford to pay much or anything.
American Medi-Plan (SM) does not have to disrupt the current industry structure. Insurance companies can continue to exist as they take over more and more of the functions that governmental bureaucracies undertake today. We would encourage different carriers to come up with more and more innovative methods and computer software that will help catch problem people and providers and come up with incentive and penalty systems that will fine tune the operation of American Medi-Plan( SM).
Doctors will go back to doctoring, and housecalls will return to the extent people want to pay fairly for the time consuming call. There will be less waste in lab and X-rays because patients will tell their doctors the patients will assume the risk so that the doctors won't feel the need to practice defensive medicine, to do lab tests just so that they won't get sued in case of the rare chance that the lab test will uncover something. Doctor-Patient relationship will go back to how it was, on Marcus Welby, MD (for those who are ancient enough to remember that popular TV show about a kindly, caring doctor).
When you connect the payer to the person who gets the care (and not Blue Cross), somehow, providers of care become more attentive to those from whom they must get paid. Doctors will feel that the system is fair; they won't get $3.50 after a call in the middle of the night to the emergency room, like I once got. That will make him or her less reluctant to go see their dear patient late at night.
The American Medi-Plan is far better than the Single Payer System. Read my note of April 8th about the bankrupt Canadian Single Payer System. Those of you in legislation; you don't have to feel awkward in calling on me. I already know a lot of you are reading here. You have an opportunity to save America from going down the tube, health care-wise. If we get Single Payer, don't let me point fingers and tell you when it is bankrupt, that "I told you so!"
April 8, 2007 From time to time, I receive for review and for my interest socio-economic papers, and one caught my attention written by some Canadians about a crisis they are apparently facing right now with their single payer health care system. I want to reproduce a passage from it, because I think those in the legislature pushing for a single payer system should take note of this alarming report.
"Health care. The health care system in Canada is on
the brink of collapse, unable to meet the needs of Canadians and its aging population,
unable to provide care in emergency rooms, and unable to find qualified people in Canada
to fill the services gaps. We had an illness in our family last year and were told it
would be ten months before an MRI could be done; we went to a private service, paid $1,000
and were done in two days. A woman in BC died in the emergency room after waiting eight
hours to be seen. In Ontario, a man had to wait so long for a mandatory cancer treatment
that he returned to his home country and paid $5,000 for the surgery there.
The writers go on to say that the Canadians are seriously considering privatizing their system!
I was aware of these problems in many countries around the world with a single payer health care system, but to hear that many in Canada are actually considering privatizing their system is indeed sobering. I will plan on writing more below in the next week or two. To read my last entry of March 22, please scroll below.
March 4, 2007, March 22, 2007
When after the below posting on the 14th, we did not see the usual surge in visitors to our website, I thought, oh, finally, they've lost interest in what we say here because we are no longer threatening another recall effort. Then I posted an addendum here on the 18th and we saw a huge number of visitors. So as long as I see there's interst in what we post here, I will continue. Once again, while I continue to be in close touch with most of our recall lieutenants across the state who continue to monitor the Governor's activities, recent postings do not necessarily reflect the concensus viewpoint of the Recall Campaign. The recent postings are my views and only mine. I have to report that there are valued volunteers who are expressing dismay at my saying anything complimentary about the Governor, and I fully understand. There are some issues that they feel have not been corrected, and about all I can say is that I am sorry, but that I have not forgotten those other issues, and I trust that over time, we will see changes. Do not think for a moment that I do not care about those other issues. The road to a kind and just world is a tortuous one, and sometimes it may seem we are traveling tangentially west when we really need to be going north. I know that I am taking this Campaign on the best road, and we will reach our destination to everyone's satisfaction. I ask for your patience.
Before I make further comments about healthcare, I would like to say a few words about other issues with which the Governor and the legislature are grappling. On the matter of the dam north of Sacramento, I understant the objections and concerns. Some of the thinking, however, may be old since this issue was visited sometime ago, and I think we need to review earlier conclusions.
Generally, I am opposed to dams for two reasons: environmental impact. (1) They are not natural, but human-made, and it involves a resculpturing of California landscape in a major way... no colossal way. (2) I think a dam gives terrorist yet another target. A big target. Imagine the tremendous loss of homes and lives if one of those dams give away. I am not optimistic that by leaving Iraq, the fervor of the Islamic terrorists will dissipate.
Having said that, however, my mind is open and is leaning towards a support of the construction of one or more dams if many of our concerns can be worked out. That is a big if, but I think we CAN work many of the concerns out.
The reason I am leaning towards Governor's proposal is that we have a major threat against the environment in the guise of the global warming. That alone will sculpt California seascape and landscape like nothing else has ever done. Hydroelectric power is far superior to generating energy than coal-powered generators, or the newer, safer nuclear reactors, for the environment.
(I do think one of the most important things California must do is to limit the flux of people into our state. For sometime now, I've subscribed to the humorous road sign, "Welcome to California. Now go home!" The quality of our homeland will decay unless we take steps to limit our population, esp. from immigration of other Americans from other states. I realize that economic growth requires influx of people to fuel it, but we need a balance. I will prepare a statement about this population concern sometime in the future.)
I interjected my opinion about population growth because the need for more electric power is driven by population growth. Even without growth, we appear to need more electricity than is readily available from intra-state sources, and a new dam can help this need decades into the future. It is true that aside from a curve on population growth, we will also need to re-educate our population on conserving energy. I see we have gotten enamored of the idea of stringing pretty lites across bridges and down all our main streets, even when we don't have a need to provide guidance to Santa's sleigh. This is one example of how wasteful we have become, nevermind that the lites downtown help the public spend more money.
Another reason I favor another dam or two is that regardless of the valiant effort of Gov. Schwarzenegger and all the other governors across the country who have declared their wars on global warming, we are still going to see more warming for a decade or two, at least. The tremendous climate changes that we have seen this decade will worsen and California could see wilder swings of too much rain and too much drought. I believe that dams can perhaps soften the blow of these erratic climate changes. I realize that the scientists have not come to an agreement on what we can expect, and so I do make my statement conditionally.
There are many claiming to be knowledgeable about budgets who say that the governor's projections are too optimistic and that we will face a deficit. Some of them are proposing a cut in the education budget. Seems like life in California is circular and we are coming back to the same point we were a few years ago? I do think that the education sector should prepare for the worst. I met many teachers during the Campaign. You all know how vital a role they played. Indeed they were a major part of the skeletal structure of the Recall Campaign. Nevertheless, there were teachers who took me aside to tell me that they felt that the education budget can be worked out better to cover more territory with the same dollar. Some will surely disagree. I think it behooves those in charge to make sure that if a budget crunch happens again, we don't begin hacking into what I consider essential, like PE or art or music. Perhaps the CTA was taken by a surprise when Gray Davis was taken out and replaced by a Republican Schwarzenegger and so they could not work out a reduced budget any better than they did. THis time, I think the leadership in Burlingame should prepare for some budget cuts, just in case that is going to happen. I will count on them to look for cuts that will affect our children less the next time.
There's a lot of talk about our prison system. I see that the governor would like to house some of them elsewhere where there's more ample space, and where costs are less. I think this is getting into some turf battles, unions naturally concerned about precedents that can affect them economically. I ask all parties to keep California first in their minds.
My statewide Campaign coordinator and I had lunch a little while ago in San Francisco, and we talked about some changes that can benefit California. Jeff had a lot of good ideas, not surprisingly. I added some of mine that had been percolating in my mind for years. Some of these ideas pertained to prisons, and I look forward to sharing them with you in some future postings.
What we do see is the waste of a great natural resource, human beings, who because of various and varied reasons, they are incarcerated. I think crimes could be substantially reduced by making societal changes. No, I am not one of the "liberal apologists" who provide excuses for those who commit crimes. However, I am also not blind to what everyone could see about the wrongs in our society, the worsts of which is not to mold our society better to fit more people, not the 70% who can adjust to it currently. Why do we want to punish us, conservatives, too, by not making these simple changes that causes us to pay exorbitant insurance rates today? More on this, too, in the future.
SO we are back to healthcare. Like I said below, my initial intent was to offer a few humble advices, which then grew to a rooster crowing magnificent ideas. I saw that it is much more useful to offer concrete ideas rather than broad concepts, and then came much more work to come up with concrete ideas. This project is taking on the characteristic of a bureaucratic department's budget, growing in leaps.
Once we began to work on concrete ideas, it needed to be a complete idea, not some animal that had a head but no legs. It needed a catchy name, and the American Medi-Plan was born. (I was amazed that if one puts this term, our website comes up, as the only listing. Google found us within a week, I think. Because if we are at all serious, we need to make a claim to this name so that others don't begin using it and confuse people, I will hereinafter append a Service Mark SM to this term everytime it appears. )
The American Medi-Plan (SM) is still undergoing polishing, but those of us working on this realize that we really need a transition plan to make all of this transformation in American medicine smooth. Remember, I claimed that if America Medi-Plan (SM) were in effect today, we could save as much as 55% of our healthcare dollars. Obviously, if that were true, someone is going to have less money since the public is spending less money. In this case, this "someone" isn't a singular noun, but plural. THis is troubling because when you threaten someone's pocket book, they complain, and complain loudly. If it is just one group of people, like the insurance company, one may be able to get away with it, but if you are chipping away money from a whole bunch of people, it's called a political suicide. Good thing I'm not running for an office, huh?
We believe it is not realistic to put the American Medi-Plan (SM) in its full glory suddenly and at once. I think it is more realistic to talk about a five to ten years future when more and more of this Plan are implemented. What is important is that we begin to move in the direction of full implementation.
Just as it is more palatable to talk about a "cutback" at the workplace that is achieved mainly by attrition, I believe we can realize the American Medi-Plan (SM) without chopping off an arm and a leg from each sector of our healthcare family.
So when I finally unveil the American Medi-Plan (SM), I can assure you it will not be flawed like the Single Payer Plan approved recently and vetoed by the governor. You may recall last June, I cautioned each candidate to not embrace this Single Payer Plan, because I detected that the voters were not prepared to embrace it. It called for too radical a change in the healthcare landscape, including the elimination of private insurers. In retrospect, I am amazed that all these sophisticated people in the legislature did not see that they charged forth without seeing if their people were behind them.
I do not blame my friend Rose Ann De Moro for embracing the Single Payer Plan. She is sincerely despondent over the lack of equal care to all segments of our population. Tbe Single Payer Plan by design would take care of all the people. If I did not envision yet a better plan, I would be embracing this plan also. However, as I point out in my Feb 14th posting, I do not believe we have to lower the standard of care to those receiving currently higher care, in order to extend the care to the working poor who so deservedly need them. I ask Rose Ann to consider the American Medi-Plan (SM) as achieving what she would like to achieve in healthcare.
I think what I will be proposing will seek to cut back the growth in healthcare expenditure, so that pretty soon, it will take less and less of our overall expenditures. By this means, I can enable more sectors of our healthcare family to adjust to the new norm.
In case, you have read this far hoping that I will unveil my American Medi-Plan (SM), I should caution you that I anticipate it will be awhile yet, since I have determined that I need to modify it to give it a better chance of a safe and effective delivery, for the baby and the mother as well. I do want to clarify one thing from our previous posting.
A major feature of the American Medi-Plan (SM) is to restore the connection that is needed between the person who is receiving care with the person who is paying for the care (needs to be the same person for both). Recently, a dear friend called me almost livid because of what he perceived as mistreatment at a local hospital of his elderly mother. She has renal failure from diabetes, and was admitted for "failing to thrive." She usually undergoes dialysis thrice weekly and her doctor ordered upon admission very early in the morning, to do a dialysis on her. My friend was angered when he visited his mom at 6 pm that night and she had still not been dialyzed. They wanted to start at 6 which meant she could not eat her dinner because she gets nauseated from dialysis. In the end, both the mother and the son refused to allow dialysis so that she could eat her dinner. The dinner came, and it was a cold turkey sandwich.
Do you think if the primary doctor was expecting to get a payment from this family directly, and not from Medicare, that he might have bothered to keep checking throughout the day and urging the hospital staff to do the dialysis at least by mid-afternoon? You betcha! Do you think if the dialysis section was also expecting to have a check written by the patient, they may have rushed to do the dialysis to keep the patient happier? You betcha!
If this was a case of an ordinary merchant, they would have to offer to do the dialysis for free the next day for "flubbing." But no, they don't care. Medicare will pay them anyway. Medicare doesn't know they "flubbed!" Do you see how the disconnection between the party receiving care and the party paying for the care has caused a tremendous erosion in service quality? I guarantee, under my American Medi-Plan (SM), doctors will once again begin making housecalls. Rose Ann, isn't this a better plan? Under the Single Payer Plan, the same disconnection will exist and in fact now with only a single payer, there's no more competition, and you can expect a tremendous deterioration in healthcare in the United States to those who are already receiving care.
February 14, 2007 (modified on Feb. 18th)
Dr. Kenneth Matsumura:
The following paragraph was added as a preface, on February 18th.
PREFACE: The development of the American Medi-Plan, a reform in how America provides healthcare
Much of my activity related to Gov. Schwarzenegger has all been a spare-time effort on my behalf since I have a more-than-a-day job as chairman of Alin Foundation, the world's oldest biotech concern. I began to comment on various political moves to improve Californian's healthcare, such as the Kuehl Single Payer Healthcare Plan, mainly only to assure that a support for any plan does not cause a candidate to lose an election. On this website, I've offered my own thoughts from my three plus decades as a physician. When Governor Schwarzenegger recently embraced my concern for the working poor without health coverage, and saw that he would have political troubles getting his bill through the legislature because of the price tag his plan was perceived to carry, I began to more seriously think about how healthcare today can be reformed so that I can be sure that my working poor patients will one day have their nightmare end.
Much in the way I have found solutions to major diseases in my laboratory, I began to approach the problem of healthcare in America as something that can be cured quickly, and indeed an early exploration of new models for healthcare appeared promising. As such promising models began to emerge, I began to recruit resources of Alin Foundation, and now the development of what I have coined, the American Medi-Plan (SM), has become a serious effort. The ultimate model of healthcare has been easier to develop than how to implement it, in the political atmosphere, with every special interest protective of its economic consequences, and indeed that phase of this project is currently ongoing.
state of the American healthcare can be likened to a classroom. In a classroom that has bred some of the
worlds top leaders in their fields and in a classroom that has also sent a huge
number of students to Americas top universities, we have some students who have just
not done well. Because of the students who have done outright awfully, the
average performance standard measures poorly for this classroom. The critics
frequently cite these performance figures to argue that we should completely dump the
American healthcare system in favor of a Single Payer System, more or less modeled after
what most of the world have. After all, the critics say, so many other countries are doing
Lets look at the classroom analogy. Faced with some serious deficiencies in our classroom, what do you do? Do you decide to make radical changes in the classroom, in order to help the students who have done poorly? One thing you can do is to dumb down the class so that you can make sure that the poor students dont get lost. Probably without the poor students completely flunking out, the average performance of this class will improve, but imagine what will happen to your brilliant students, and the above average students.
The Single Payer healthcare system is like the dumbing down solution - dumbing down the classroom to help the minority of students at the terrible expense to others. There are other ways to get help to the poor students without making everyone else take such a heavy toll. The Single Payer system is like throwing out the baby with the dirty bathwater. The baby is outstanding; we just need to change the bathwater.
It is now time to provide a high performance healthcare to the working poor. The unemployed poor have had the federal-state Medicaid system, which, when it started back in the 1970s, based on my own experience tending the poor in those years, surpassed the care the patients today get who have Blue Shield.
There are two things we must do to fix our healthcare system so that our average performance isnt surpassed by 40 other countries. Remember the analogy of the classroom and why refusing to take care of the working poor pulls our average down. The first thing we must do is to change the way we pay for healthcare and change the way we make healthcare decisions in America so that we can cut the cost of healthcare to about 45% of what we pay today and so that in ten years, we will pay about 20% of what we will pay if we dont make this proposed change. More on this first step later, after I talk about the second thing we must do, first.
We must extend the current Medicaid system to the working poor, who cant afford any kind of health insurance. Weve tried mandating companies to pay for health insurance, and a few people have bought some kind of health insurance on their own, but the statistics show that ¾ of those who bankrupt on account of medical bills had health insurance of some sort. When you force businesses, many of them teeter-tottering on failing, to pay for health insurance, they will be able to afford only minimal insurance, and you dont have much improvement for the working poor. You have to instead spread the cost of insuring the working poor to a larger pool of people so that each segment of the society bears smaller, more manageable tax.
Medicaid to the working poor will fix the average performance of American
healthcare so that it will far surpass every other system in the world. However, one does
have to keep in mind that comparing the performance of the American system to another
system in another country may not be entirely fair or useful because
It isnt as expensive as one may initially think, because the fact is we are already taking care of the working poor. We wait for them to make medical care drain their bank accounts, some even into bankruptcy. Then, guess what? They become qualified to be covered under the Medicaid program, because now their income and assets have become low enough. So when they become very seriously ill, we take care of them, at taxpayers expense. They often go to the county hospitals, and who pays for the expenses of the county hospitals? Yes, you and me, the property taxpayers. A few end up going to private hospitals, and when they end up with a $5000 bill or a $50,000 bill they cant pay, who pays for it? Yes, you and me, again. This time, we pay because there is something called cost shifting that goes on at non-public hospitals. When hospital operating costs are not met because some of the working poor couldnt pay, the hospitals just raise the price they charge to the rest of the customers. So the plastic bedpan that comes with a price tag of $20 is expensive because $19.50 of that charge goes to pay for the nurses that took care of a working poor patients who couldnt pay the hospital.
Often the working poor will ignore medical problems until it has become a crisis. So instead of going to the doctor regularly, paying maybe $300 per year and controlling the blood pressure, they wait until their blood pressure blows a blood vessel in the brain and they have a paralyzing stroke. They are rushed to the emergency room, barely breathing, spend $12,000 there, being stabilized enough to be moved up to the Intensive Care Unit, where they will stay for five days at a cost of $2500 per day, and then they move to the regular hospital room for a long, protracted and expensive stay. A battery of consultants is called, and expensive and long rehab program is started. If they are lucky (many are not), they leave the hospital after three weeks and a $130,000 bill, to be transferred to a skilled nursing facility. There they will proceed to spend your and my money to the tune of $5000 per month for many months. Some never make it out, and we are stuck supporting them at a rate of $60,000 per year. These are people who could have been continuing to work, if only we had helped them with $300 per year. They might have been earning $30,000 and may have been paying as much as $5000 per year to the public coffer in various forms of taxes, federal income tax, state income tax, property tax (even if a renter, they are subsidizing the landlords property tax), and sales tax. So you see, because we Americans have not been kind enough to pay for the healthcare of the working poor, we have ended up spending over ten years on this one patient $750,000, and we have lost the tax revenue from this no-longer-working poor to the tune of $50,000. We taxpayers would have spent only $3000 over ten years, if only we were more compassionate.
So giving healthcare to the working poor may seem initially expensive, but in my estimate, it will return the money at least two times, and probably more. We taxpayers and we voters are very shortsighted, and can only think about the increased tax next year. All the promise of reduced tax four years from now makes no difference, and this is why we have not had health coverage for our working poor. It is time to wake up and think. You can actually make money by being kind and helping the poor!
Giving healthcare to the working poor will end up lowering private health insurance premiums because cost shifting will cease. However, we have to be mindful of something. Just as it is difficult to lower taxes once you raise them to fuel all kinds of programs, insurance companies cannot be counted on to lower the premiums even as they see their payouts become smaller.
Giving healthcare to the working poor will end up reducing the budgets of county hospitals because more patients will seek care at less busy private hospitals. However, if we are not watchful, the county hospitals may end up padding their budgets, keeping on personnel they no longer need, and generally justifying unreduced operation.
Employers who pay for their employees healthcare will see a drop in their cost, but one cannot count on them to pass on the savings to their employees as dividends.
It is for the above reasons of insurance companies, county bureaucrats, and employers behaving as one can expect them to behave that we hear talk today that providing healthcare to the working poor will actually cost something. If instead we work-in to the new program, means for rebating to the Medicaid system from the insurance companies, county coffers, and employers, we can actually eat the cake and have it, too.
Further modifications are required to return Medicaid to the first class service it almost was back in the early 1970s. Today, the Medicaid system is so overrun in cost that there have been terrible cutbacks and now Medicaid is a second class system. What is not known is that there are excesses in the Medicaid system in terms of the kinds and amount of service provided. While it has cut back right into the muscles and the bones of healthcare in certain areas, it has completely missed fat that should have been trimmed. I am confident that we can once again attract medical specialists to rejoin the Medicaid system so that an appointment with the one dermatologist in the whole county willing to accept the meager payment by Medicaid will not take 8 months.
The purpose of this first of many articles to follow on my vision of the New American Healthcare System is to provide some overview of areas we will be visiting. Rest assured that we will go into details of what we will need to do in the future.
The change I propose above, of extending Medicaid to the working poor, is actually only the second change we must make. It is the easier of the two changes I suggest and in fact it is just an interim stop gap measure while we work to bring about the difficult first change.
The first change we must make is an entirely more fundamental modification in the way providers of healthcare are paid and the way healthcare decisions are being made today. Future articles will cover this proposed first change in details, but a preview is in order.
I would also like to say that not everyone will like what you are about to read. By showing a lot of interest in what I have to say (for which I thank you!), you have in essence asked me what I think about the healthcare debacle today. Youve asked me what I think needs to be done to end the nightmare. I promise I wont simply say, to take two aspirins, get a good night sleep and call me in the morning.
Some of our readers are new and wonder why anyone would care what I think. Im not going to show false modesty and say I also wonder why anyone would care what I think. On the contrary, I have to say I have become more and more amazed what ideas I come up with, how I am able to analyze a problem right to the root cause and quickly find answers when tens of thousands of our brainiest scholars cant seem to do the same. I scare myself sometime with my ability to take just a few clues, and extrapolate from them a whole Ph.D dissertation-worth of probable truths surrounding the clues. Quite often from those few clues, I see logical consequences and see what the future holds. I am amazed what paleontologists can discern so much about an ancient beast from one piece of bone. I guess I am able to do that about many things.
I recall way back what seems like a century ago, when I had just emerged from my teen years, when I was intrigued reading about how difficult it would be to create an artificial liver. Journalists and scientists detailed how complex the liver is and the fact that we dont know all that it does, and so how can you artificially duplicate what we dont fully understand. I saw, however, that the key word was not artificial and no one was giving an award for coming up with something nature does so beautifully. I saw that the goal was, to create a device that can be used to artificially support someone whose liver was failing, even perhaps temporarily so that this someone would not die while his or her own liver did its own wonderful thing, to repair and regenerate that which a disease had destroyed.
I came up with a concept of a bio- artificial liver, a hybrid device, part plastic and part living. By taking liver cells isolated from a whole liver organ, I was able to place them in a disposable artificial kidney device such that when the blood taken from an arm of a dying patient is passed through this bio-artificial liver, the blood is somehow cleansed and augmented by the liver cells that are in the device. The liver cells in the device are kept from being washed into the flowing blood by keeping them behind a semipermeable membrane that governed what blood components are allowed to pass through and what are not allowed.
over forty years later, this device is still being tweaked and is still not generally
available, the device has already saved scores of lives, including the life of an eight
years old girl in
The reason I mention this is not to show off (frankly I have also come to not care whether anyone knows what I have done the reason for the recent book about the governor has little to do with my need to take credit than for other reasons, like letting our volunteers know that their efforts paid off). I mention my conceiving the artificial liver as an example of solving an insoluble problem.
I do feel compelled to tell you one more thing, to rub in my ability to see things that millions of others do not see, in order to give you the sense that what you are about to read about the solution I see for the American healthcare nightmare is something that needs to be taken seriously and implemented.
A solution to cancer has escaped the human kind for centuries. No, Im not stupid enough to risk the credibility of everything else I say from here by claiming I have found the cure to cancer. Of course not, but I have to say, I am pretty amazed with what I have come up with. For those of you with loved ones dying right now, let us hope we can move fast enough to make this therapy available in time; it cannot be made available to the public yet.
Back in the early 1980s, everyone, including myself, was looking for the way to focus the effect of toxic cancer drugs to only cancer cells, and not to the cells of the gastrointestinal tract or the bone marrow, which are undesirably affected by todays chemotherapy. These unintended effects result in horrible side effects like vomiting and weakness so that the treatment is worse than the disease. Patients choose death over therapy that ties you down to years of making you feel awful.
Most everyone was looking to deliver the cancer drug to only cancer cells so that the effect of the cancer drug would be more focussed and not like a shotgun. We looked for an epitope that was unique on the surface of cancer cell alone so that we can piggy back cancer drugs to some type of a homing protein that would find this epitope and bind to it. Once bound, the cancer drug would get off the homing protein and attack cancer cells. The homing protein would not bind to other normal dividing cells of the body and so those normal cells would not get sick.
Unfortunately, we were finding out that there were very few epitopes that were unique to cancer cells alone, and that even when we found something that are found mostly only on cancer cells, a few cancer cells didnt have them and those few cancer cells would not get killed by this scheme. We realized that it took only one such cell to eventually multiply and kill the patient.
I was one day sitting in a continuing education conference for doctors and something struck me. What came to my mind then has now spawned a therapy that has little or no side effect and eradicates cancer more thoroughly than anything the human kind has come up with ever.
What occurred to me is that cancer drugs are poisons, and so anyone who read fairy tales as a child knows that poisons have antidotes which totally neutralize the bad effects of the poisons.
It also occurred to me that it was easy to find epitopes that are found uniquely on every normal tissue cells which are not found in the same concentration on cancer cells. What I thought of was to deliver antidotes to normal dividing cells, but not to cancer cells. If all the normal cells in the body got the antidote but bad cancer cells did not get much if any, treatment with the cancer drug would result in the death of only cancer cells and there would be no side effects.
My treatment concept, you realize, was exactly 180 degrees different than the approach everyone else was taking. I was targeting antidotes to normal cells, while everyone was trying and failing in their attempt to target cancer drugs only to cancer cells.
Now we have found out in clinical trials that because we are able to spare the white blood cells of the immune system during chemotherapy from harm, the white blood cells can do what they are programmed to do, that is, to find and dissolve cancer cells that are partially damaged from cancer drugs, the cancer cells which otherwise can repair themselves to kill the patient. Where in conventional chemotherapy, the cancer drugs kill outright only perhaps 20% of the tumour cells, although damaging perhaps another 80%, and so the tumour shrinks slowly 20% at a time, we have found that, like in patients with many cancerous nodules in the liver from a deadly breast cancer, after only two cycles of treatment with an ordinary cancer drug together with our side effect-eliminating agent, all the nodules are found to dissolve, to liquefy. The liver looks like Swiss cheese with voids where cancer nodules had been.
I think this new therapy is another example of the way I am able to find a solution that has escaped all of human kind. So you see me pumping up so that you will take me more seriously what I am about to tell you about the American healthcare. I have to tell you one more thing in my preface.
I am able to speak my mind here because I am not beholden to any group or to any special interest, a term our governor has made popular. I am interested in only speaking the truth that I see, and speak them because I see a horrible world in the future if I dont.
I also have absolutely no interest in holding any public office and so I can speak freely the truth. To me, to become a governor or a President, is like being sent away to the penitentiary for four or more years. I have a lot of respect for those who agree to run for an office, because I know there is no way anyone can get me to run. This lack of interest in a public office however gives me incredible freedom to say what I want to say. Governor, dont you wish you could say what you want???
I am about to tell you I tell you without thinking about the impact on the bottom line of
all the special interest groups that provide the American healthcare. I mentioned at the
beginning that my proposal could cut
I do not make my proposal like a Rambo who callously knock over and destroy everything in his path. I make my proposal because no human is an island; members of any special interest group can stay happy only if others around them stay healthy and happy. We are today walking towards a catastrophe, an explosion in healthcare spending that robs us of every other thing precious to us. I call on the special interest groups to put the good of their fellow humans first and to read-on suspending feelings of threat my words portend.
When in the 1960s, Medicare came, we unfortunately set it up in a way that created the nightmarish explosion in healthcare expenditure. Thanks to the pattern that Medicare established in how healthcare is paid, we have all grown accustomed to thinking loosely about how we pay for healthcare. Most of us think that theres a rich uncle someplace who is paying for our X-rays and doctor diagnostics, and for ever-and-ever more expensive medical tools like drugs, devices, and supplies.
I guess we have an uncle. His name is Sam, but how rich he is, is becoming very debatable.
I have been a doctor for 36 years. I have met and talked to thousands of patients. I have had a thriving practice and have been a major utilizer of our local hospitals. I know healthcare down to its core.
Today, concentrating mostly on my medical research, my income is not dependent on patient care. My words are not tainted by self-interest. Almost none of my best friends are doctors, and so I can speak more freely.
I do, however, talk to colleagues about what motivates them and what worries them and what outright bothers them. I have kept up with the incredible and often horrible transformations that American healthcare has undergone in the last forty years. This is the same period in which hospital administration grew from a few rooms and an administrator or two into many floors in a skyscraper far away from the hospitals. THis is the same period when most hospitals are parts of a huge billion dollar conglomerate. We are popping out junior execs faster than rabbits pop out bunnies in the prairie. There is something bizarre when I had to include bureaucrats in my terminology of providers of healthcare.
Most of us have had a battery of tests ordered when we go to our doctors, and while we may have deductibles, the diagnostic charges do not usually break our bank and we go along without asking too many questions.
Most of us dont know enough science or medicine to ask if the pill just approved by the FDA that costs $5 each is the only way to treat our condition. Some of us who dont have a prescription insurance do ask, and we are prescribed something less expensive but are left with a feeling that we are getting second class treatment.
Many of us occasionally glance at a statement from the insurance company or a government payer like Medicare and see what payments have been made to doctors and to suppliers of medical care. We might think, the charges we see and the payments we see are not commensurate with the services we received, but we keep our mouths shut. First, it hasnt cost us out of pocket that much, and we are too busy with day to day living to raise a fuss.
Most of us ask for and vote for laws that regulate healthcare merely because they sound good, but rarely ask what the costs are for having them. Will we have agreed to pay millions extra for something that affected a few dozen patients in a period of ten years? Are we worried that many of the laws are passed in the last waning days of a legislative session when the legislators have simply run out of time and when they do what they can.
My recital of what has gone wrong can go on for pages after pages. It was my intention to only list a few. Correction of these wrongs can end up not only saving billions but enable us to provide more and better healthcare by eliminating wastage and getting rid of non-healthcare spending from the healthcare budget.
Do you see doctors making house calls anymore? Do you know very many Marcus Wellby, MDs? Are you on your own when darkness sets or the weekend starts? Has medical care become less and less personal? Did you think all these things that we used to take for granted are no longer possible because we can barely afford what we get now? Would you like to have them again? You created the mess, and you and you alone can get yourselves out of this mess.
I will offer initially only broad concepts for change, but the changes I propose deal only with how we pay for healthcare and how we make healthcare decisions. Im going to put you in the driver seat once again. You can get off this frightening roller coaster. If you ever got on one, did you not immediately think, oh, my gosh, I made a mistake. When will this ride end? I am offering you the ability to get off the roller coaster and get on something more suited for mature adults. More soon.
(I will be posting subsequent installments to this article. I promise no set time schedule, but definitely at least once a month, before the 15th of any month.)
March 22, 2007
I don't think a readers should read the following without having read what I have written above. This is why I have chosen to append installments below previous installments. Sorry if you have to take a rapid down elevator to get to the cellar to read what is new.
You can see from what I have written that I am pointing out broad concepts as to what has gone wrong with our healthcare. Wait, from here, I am going to spell the last word of my last sentence, health care. It must be some industry people or some government bureaucrat who turned it into one word. Perhaps not, but in any event, to me "healthcare" sounds like an industry. What we are talking about is caring about health, taking care of one's health.
Like they say, it is better to teach someone how to fish, then to give them a lot of fish. I think if I teach the concept, important people who will change our state and our country will know better about what direction to move us. The solution I will ultimately offer will be just one way to incorporate the ideas I am teaching and in fact there may be other solutions that will incorporate the ideas even better. It is also for this reason that I offer the basic concepts first.
One thing I have learned is that there is no substitution for bringing together many fine minds to critique any proposed solution. Quite often, other scientists and lay people tell me after I've taught some novel concepts, that actually my ideas are pretty obvious, certainly obvious to work, and why didn't anyone else think of it? After I brought into this world the new concept of a hybrid organ, dozens of others came up with different ways to use the basic concept than I described initially. However, these others could not come up with their lifesaving designs until someone taught the basic concept. I look forward to others offering schemes that incorporate basic ideas I teach here that will enable us to evolve the idea. From Wright brother's double-layer wing design that incorporated the idea of a "lift" came Concorde, the supersonic transport with a single layer wing design.
In that spirit of teaching, let me share with my readers a day in a doctor's life. I think if Congress members, back when Medicare was implemented, knew a little more about the practice of medicine and how decisions are made, we could have saved trillions of dollars over the course of 40 years. A lot of "dumb" laws are still being passed, often in response to some well-intentioned constituent's single-minded causes. We pay for this, and errors tend to compound, and after a decade, the mistakes turn into billions of dollars.
A patient comes to me, complaining of feeling easily fatigued, onset being about 6 weeks ago. There is no lightheadedness or palpitation. There is no symptom of bleeding from anywhere. He reports no feeling cold when everyone else is warm. There is no loss of hair. There is no weight loss and no pain anywhere. However, his energy level by 3 pm is so low he finds himself falling asleep.
Beep. What's the diagnosis? I've described something that hopefully will enable most doctors to immediately home in on the most likely diagnosis, but there may be doctors who won't have a clue so far. If the doctor doesn't have a clue, then a wild-goose chase can start, with a whole battery of tests, and costs start adding up. In a situation like this, a computerized guidance towards diagnosis can be useful. Obviously, we need to train doctors better, but then it is also a matter of the IQ and the society probably cannot be served sufficiently if we limited doctors to only those with the highest IQ. Remember that the practice of medicine is not only diagnosis, but holding hands, reassuring healthy patients, and showing care. Many doctors with lesser IQs do very well in patient support, and many patients will often choose caring doctors over cold computers. So what's the diagnosis? Keep reading, I promise to tell you.
Some patients will come and need radiologic tests. Actually, if the clinician is truly competent, he/she doesn't need to always order x-rays to diagnose a problem. Usually, I diagnose my patients in the first 30 seconds of their interview, usually without an examination that involves touching. (I am examining the patient from the moment I step into the exam room, the way he is breathing, or the way he sat down, the way he holds his arms, or how his face looks.) An examination is done to confirm more than to diagnose, but many doctors will tell you otherwise, that they didn't know until a surprise finding on an exam clued them onto something.
We used to train doctors better I think. That is another area towards which to put some effort. We are now producing more and more doctors who rely on a diagnoses made by specialists or on tests, and this is sad because a referral to a specialist delays the diagnosis and specialists charge a whole lot of money. Tests are also very expensive.
Then there's the choice of tests. Some are more expensive than others but for what a clinician is looking for, the cheap tests are often just as good. However, not rarely, a patient will name the test he or she wants, for example, a CT of the chest. Often a plain ordinary chest x-ray is enough, which costs $15, although pricing nowadays is padded. If the patient was paying for the test, the patient is less likely to choose the most expensive test.
On the matter of patients actually paying for tests, and for other medical care, it has been pointed out that patients will then generally delay seeking medical attention until their diseases become advanced at which point the treatments will be more costly. Well, of course, if one concocts a dumb system, you can do more harm by giving patients more control of medical care spending. However, if the initial entry into the health care system for a symptom is free or if there is an incentive worked in that will encourage more patients to seek preventative health care (checking blood pressure regularly, getting PAP smears, or checking stools for blood), then you obviate that problem of patients delaying diagnosis until it is too late.
Then too, once the patient is in the system, and certain tests are necessary to reduce future costs that may result from delaying tests, one needs to provide incentives to the patients to get those test done. Therefore, a simple "make patients once again responsible for paying medical bills" is not what we need.
Since we are going to have smart doctors and dumb doctors, a computerized guidance system will help reduce cost tremendously for determining how a "work-up" of patients will proceed, in terms of what questions would be asked the patients, and what choices of tests and referrals will be made.
Quite a bit of new research and development is being devoted towards such artificial intelligence, but if one considers how much money continues to be squandered for the lack of such computerized guidance systems, one is not spending even 10% of what we should be spending today toward the development of such computerized guidance systems.
Such artificial intelligence can reduce so called "practicing defensively" by doctors. The defensive practice of medicine really started when malpractice suits became more and more commonplace. Doctors would order more tests than necessary because that way, he or she is "covered" just in case, in a rare instance, the diagnosis hinged on doing such low yield tests.
Now, let's get back to the hypothetical patient above, with easy fatiguability. I asked him if he was sleeping well, and he said, no. He has trouble falling asleep and then he wakes up after only three hours, after which he tosses and turns and can't fall asleep again. Most insomnia cases are due to depression. Depression is anger that hasn't been expressed outwardly satisfactorily. Anger that has been shuffled under the carpet, so to speak. Suppressed anger will lead to nervousness, jitteriness, and insomnia.
My patient related that he has been bothered by his teenage son distancing himself from his father (the patient) because of the influence of his mother, the patient's ex-wife. He doesn't know what to do. Not sleeping at night starts him off in the morning already tired. By 3 PM, he is almost dead.
Although insomnia can explain his fatigues, it is still a good idea for a doctor to make sure he doesn't have other underlying organic causes. Therefore, I would order some basic tests, such as a complete blood count, a chemistry panel that assesses his liver and kidney functions, and a blood test for thyroid function. If he has not had a chest x-ray recently, this would be the time to do one. If he is old enough, I would also order a prostate blood test. These are all very inexpensive tests that uncover some serious conditions, which if discovered early can save lives and save money.
Because how a doctor treats such a patient as described above can vary, I won't go into what I would do, except that if on this visit or a subsequent one, I decide to medicate him, then we are at a point where a decision can end up costing a lot of money.
New drugs today have become very expensive. It costs an estimated $850 million dollars to develop a drug from the laboratory to the marketplace, and that is another nightmare. Well-meaning consumers have demanded more scrutiny by the regulators, and the big drug companies have gone along with more and more cumbersome regulations. The regulations have become so complex that only the largest drug companies can afford to follow them, which leaves smaller ones behind and outside, leaving the marketplace for only the largest drug companies. Such an oligopoly invariably leads to high prices.
The problem with the regulations is that we have adopted a model of adversaries. Instead of an honor system in which penalties are so heavy that drug companies stay scrupulously clean on their own, we have a system in which drug companies don't feel obligated to help the regulators find what is wrong with their data, and the regulators are so leery that drug companies may be hiding something, the regulators take forever to finish reviewing data.
Even after getting a marketing approval, it costs a lot of money for drug companies to get the information about their new products to the doctors and the patients. Doctors are bombarded by companies about the new products, and patients keep asking the doctors about the new drugs they have seen on the television. The net effect is that more and more doctors focus their attention when they need to decide on a drug to prescribe, towards new drugs, not the old, effective drugs. In fact, if a doctor wants to prescribe an older drug that lost its patent and some generic manufacturer is making it cheaply, the doctor won't be able to even find prescribing instructions in the PDR, the Physician's Desk Reference of medications. It costs money to list drugs in the PDR, and only new drugs get listed. Consequently, more and more doctors tend to go for new drugs, which are very expensive.
March 24, 2007
don't make housecalls anymore. Why is that? A primary reason is that we have come to rely
more and more on laboratory and radiologic tests. If a doctor is at a home of an elderly
patient, with shortness of breath, the doctor may be dealing with a case of congestive
heart failure, pneumonia, heart failure associated with severe anemia, asthmatic
bronchitis, or even a heart attack. I probably could differentiate and diagnose this
patient's problem without a lab test, but I would be risking a malpractice suit if I am
wrong. Such a patient should have a chest x-ray, complete blood count, chemistry panel,
even a thyroid panel, and an electrocardiogram, especially if the pulse is irregular. It
is true, I could draw blood to send to a laboratory, but results would not be available
(to be continued)